Q: I have just picked up a young man of 14 years with a moderate degree of learning difficulties and a range of speech difficulties. He is in special school but has received very little direct therapy. He has a particularly hyponasal quality, and some hypernasality too. Would you view this as a priority? He is interested in singing and has been unmotivated by therapy, possibly due to its repetitive nature. He wondered if this might be a way to help him try a little harder with therapy. Any ideas?

Traditional SLP’s always consider nasality problems a priority

• HYPERnasality can have a devastating effect on intelligibility.
• HYPERnasal clients distort vowels by resonance and by oral position. This is a classic characteristic of dysarthria.
• HYPOnasality, on the other hand, usually has far less an impact on intelligibility. Thus, I find it less of a priority.

In terms of therapy, the approach can be the same wither the problem is hypo – or hypernasality.

• Make sure you understand the medical influence on this problem. Does the client have allergies, etc. related to the hyponasality? If so, medical intervention may help, but it may not.
• Make sure that there are no structural problems related to the hyponasality. Referral to ENT or a craniofacial team will be in order for this diagnosis. Structural problems (large adenoids, narrow nasal passages, etc.) may or may not be “fixable.”
• Singing lessons is a viable and oftentimes excellent option for a client like this. Voice instructors seem to know far more about voice and resonance than we do from a practical standpoint. They have great vocabulary and technique to teach “head voice,” “chest voice,” “throat voice” etc. My oldest daughter has taken voice lessons since she was nine years old (she’s now 20) and I have watched many of them. I have learned a lot about helping my clients project the voice in ways to achieve better resonance. It usually requires better posture, deeper inhalation and improved diaphragm control. Always it requires ear training. Singing lessons can help the client realize that there is nothing wrong with him, that he simply needs to learn a skill he does not have. If you can incorporate these types of techniques in your own therapy, you can keep him on your caseload.
• I like to use very specific techniques to teach oral and nasal airflow. I use flexible tubes in the following way:
  1. Place one end at the client’s mouth and the other at his ear. Have him produce voice and listen.
  2. Then place one end of the tube at the client’s nose. Again, let him produce voice and listen.
  3. Then place one end of the tube at YOUR mouth and nose (use another sanitary tube) and let him listen with his ear.
  4. Alternate producing oral and nasal voice, and help him discover how voice can be projected orally or nasally.
  5. Have the client feel his nose to discover the vibro-tactile element of oral and nasal voice

I used to fear facing clients with nasality problems because I found no real information on how to work with them. But over the years I developed this practical “tube” approach and have found it very useful. The key is to get the client’s ear tuned into his own voice, and to allow him time to experiment with both oral and nasal sounds. Then he can learn to control the nasality purposefully.

By the way, this activity is one in which babies engage during the cooing stage at 2-3 months of age. During this time they experiment with oral and nasal voice (without the tube), and they learn to hear and feel the differences. This is an auditory-tactile learning activity organized in the brain during the early months of life, before babbling emerges. Kids need to be able to be differentially oral and nasal in order for all the vowel and consonant phonemes to emerge.